MRIs, CT scans and X-rays for low back pain patients dropped by half last year at the UPMC health system in Pittsburgh after doctors started seeing reminders in the electronic health record that such tests can be unnecessary.
UPMC incorporated the reminders into its EHR, drawing from the Choosing Wisely recommendations from the American Academy of Family Physicians and two neurological surgical societies to avoid spine imaging for “nonspecific acute low back pain and without red flags.” The pathway directs these patients to rest or physical therapy first, said Dr. Steven Shapiro, UPMC executive vice president and chief medical and scientific officer.
Use of CT scans, MRIs and X-rays at UPMC dropped 52% in 2014 compared with 2012. Spending on imaging dropped $2.8 million and spine surgery fell by 5%.
More than 70 medical societies have recommended more judicious use of roughly 430 medical tests and interventions since the American Board of Internal Medicine Foundation launched its Choosing Wisely campaign in 2012. The campaign first focused its efforts on public education, but it will increasingly push to change the practice of medicine, said Daniel Wolfson, the foundation's executive vice president.
But tracking unnecessary care and getting clinicians to change their behavior has proven difficult. Tracking overuse has been hampered by uneven use of EHRs, which hold the most detailed information about medical history and symptoms. That detail is valuable to identify which patients are not likely to benefit from certain treatment. Claims data offer less information. Incentives to reduce overuse remain weak without well-developed measures of performance.
“Measuring these services in claims is difficult and imprecise,” said Carrie Colla, an assistant professor at the Dartmouth Institute for Health Policy and Clinical Practice.
Even at hospitals and medical groups with sophisticated health IT systems, identifying unnecessary services is complicated by the difficulty of figuring out which patients might benefit from those services in at least some cases. And once unnecessary care is definitively identified, no one is sure how best to change physician behavior or patients' expectations to reduce use.